Body Mechanics and Patient Mobility

ch a p te r
8
Body Mechanics and Patient Mobility
http://evolve.elsevier.com/Cooper/foundations/
Objectives
1. State the principles of body mechanics.
2. Explain the rationale for use of appropriate body
mechanics.
3. Discuss considerations related to mobility for older adults.
4. Discuss the complications of immobility.
5. Demonstrate the use of assistive devices for proper
positioning.
6. State the nursing interventions used to prevent
complications of immobility.
7. Demonstrate placement of patient in various positions,
such as Fowler’s, supine (dorsal), Sims’, side-lying,
prone, dorsal recumbent, and lithotomy positions.
8. State the assessment for the patient’s neurovascular
status, including the phenomenon of compartment
syndrome.
9. Describe and demonstrate range-of-motion exercises
and explain their purpose.
10. Identify complications caused by inactivity.
11. Relate appropriate body mechanics to the techniques for
turning, moving, and lifting the patient.
12. Discuss use of the continuous passive motion machines.
13. Discuss the nursing process and how it relates to patient
mobility.
Key Terms
abduction (ăb-DŬK-shŭn, p. 176)
adduction (ă-DŬK-shŭn, p. 176)
alignment (ă-LĪN-mĕnt, p. 163)
base of support (p. 163)
body mechanics (p. 163)
compartment syndrome (p. 168)
contracture (kŏn-TRĂK-chŭr, p. 177)
dorsal (supine) (DŎR-săl, sū-PĪN, p. 165)
dorsal recumbent (DŎR-săl rē-KŬM-bĕnt, p. 165)
dorsiflexion (dŏr-sĭ-FLĔK-shŭn, p. 176)
ergonomics (p. 161)
extension (p. 176)
flexion (p. 176)
Fowler’s (p. 165)
genupectoral (jĕ-nyū-PĔK-tŏr-ăl, p. 167)
hyperextension (hī-pŭr-ĕk-STĔN-shŭn, p. 176)
immobility (p. 168)
joint (p. 172)
lithotomy (lĭ-THŎT-ŏ-mē, p. 167)
mobility (p. 168)
musculoskeletal disorders (MSDs) (p. 161)
orthopneic (ŏr-thōp-NĒ-ĭk, p. 166)
physical disuse syndrome (p. 172)
pronation (prō-NĀ-shŭn, p. 176)
prone (p. 166)
range-of-motion (ROM) (p. 172)
semi-Fowler’s (p. 166)
Sims’ (p. 166)
supination (sū-pĭ-NĀ-shŭn, p. 176)
Trendelenburg’s (Trĕn-DĔL-ĕn-bŭrgz, p. 167)
The two concepts of body mechanics and patient
mobility are directly related to one another. Nursing
personnel must learn and practice proper principles
of body mechanics to prevent injury to themselves
and injury to their patients. When assisting patients
in mobility, nurses must be constantly aware of their
own body mechanics. According to the Bureau of
Labor Statistics (www.bls.gov), nursing personnel
(which includes unlicensed assistive personnel [UAP],
such as certified nurse assistants [CNAs], orderlies)
rank second in the number of occupational injuries
requiring days away from work. Nurses fall just
below the top five occupations that require days away
from work due to injuries. The vast majority of these
injuries are classified as musculoskeletal disorders
(MSDs), with back injuries prominent among health
care personnel.
Most injuries occur when nursing personnel perform
tasks that require repetitive movement, uncomfortable
posture, and exertion to assist patients in activities
such as feeding, dressing, bathing, toileting, repositioning, and ambulation. Awareness of proper ergonomic principles (ergonomics is the science of matching
workplace conditions and job demands to the capabilities of workers, especially in regard to MSDs and their
prevention) and good body mechanics helps prevent
injury.
Mechanical lifting devices (sling and standing lifts)
and assistive patient-handling equipment, such as
roller boards, sliders, friction-reduction pads, transfer
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UNIT II Fundamentals of Clinical Practice
chairs, and gait belts, work by taking on the energy and
force that otherwise are imposed on the nurse during
the lifting, transferring, or repositioning of a patient.
Regular use of lifts and other assistive devices reduces
the risk of injury (see the Evidence-Based Practice box).
Safe patient transfer requires adequate staffing, the
right mix of personnel, and appropriate, readily available, well-maintained patient-lifting equipment. The
licensed practical/vocational nurse (LPN/LVN) is
responsible for being competent in the appropriate
and safe use of equipment and for ensuring that UAP
are knowledgeable regarding proper use of assistive
devices.
Equally important is the use of appropriate body
mechanics or movements that protect large muscle
groups from injury and provide safety for patients
during ambulation assistance. Special care should be
taken in the care of older adults (see Life Span Considerations for Older Adults box regarding mobility).
Assistive devices such as splints, crutches, braces,
canes, gait belts, and walkers are available to aid in
promotion of patient activity. Also important is the
need to teach the patient appropriate positioning for
home care and to help a family member to learn how
to assist the patient at home.
Evidence-Based Practice
Evaluation of Safe Lift Programs
EVIDENCE SUMMARY
This study surveyed 200 long-term care facilities that used
mechanical lifting devices for a 3-year period. Ninety-five
percent of the facilities had mechanical lifts available for use,
with an 80% compliancy of the staff using the devices. All of
the facilities reported a decrease in the number of work-related
injuries and worker’s compensation claims after implementing
a safe-lift program. Safe-lift programs incorporated the Director
of Nursing (DON) and nursing staff to ensure that mechanical
lifts were consistently used and that all nurses and UAP were
properly trained in the use of the devices.
APPLICATION TO NURSING PRACTICE
• All nursing personnel must be trained in proper use of
mechanical lifting devices.
• Nursing personnel should strive to use mechanical lifting
devices 100% of the time that the patient’s condition
warrants a mechanical lift.
• DONs must convey the importance of safe-lift programs
and ensure that all nursing personnel use mechanical lifts
when necessary.
REFERENCE
Sheehan P: Safe-lift programs require commitment. Longterm Living 60(6):46, 2011.
Lifespan Considerations
Older Adults
Mobility
• The skin of older adults is more fragile and susceptible to
injury. When moving or transferring older adults, avoid
pulling them across bed linens because this has the
potential to cause shearing or tearing of the skin.
• Always support older adults under the joints when moving
them in bed. Lifting in any other manner increases the
stress on the joint and causes increased pain, particularly
if some degenerative joint disease exists. Explain each
step in simple language, and avoid jerky sudden
movements.
• Aging tends to result in loss of flexibility and joint mobility,
which often interferes with normal transfer techniques
and necessitates modifications to protect patient and
nurse.
• Weakness and hypotension are common signs and
symptoms noted in an older adult on bed rest. Proceed
slowly and cautiously when helping a patient ambulate for
the first time after prolonged immobility. While facilitating
independence and proper utilization of patient’s body
mechanics, use assistive devices such as canes, walkers,
and trapeze bars. Provide adequate help to ensure
patient safety when moving a patient from a lying
to a sitting position and from a sitting to a standing
position.
• Older adults who have many diseases or have undergone
prolonged bed rest have greater risk for hypotension with
postural change (orthostatic hypotension).
• Patients who use medications to reduce blood pressure
are at greater risk for orthostatic hypotension.
• Older adults, particularly those with altered sensory
perception, sometimes become fearful when hydraulic lifts
are used for transfers. Provide eyeglasses and basic
instructions.
• Limited positioning alternatives are available for the older
adult who has arthritis, neuropathies, or other restrictive
conditions.
• Discourage older adult patients from sitting for prolonged
periods of time without stretching and moving. Lack of
movement presents a risk for contractures of joints.
• Ensuring good body alignment when the patient is sitting
is a way to prevent joint and muscle stress.
• Provide patient teaching that includes use of strong joints
and large muscle groups for activities that require extra
strength to prevent strain and pain in joints.
• For older adult patients with osteoporosis, encourage
appropriate exercise programs that prevent fractures and
reduce bone loss.
• Encourage exercise programs for those older adults who
do not participate in regular exercise. Ensure that patients
consult with their health care provider before beginning
any exercise program.
• Special adjustments to an exercise program are often
necessary to prevent any problems for those older adults
in advanced age.
• Older adults who are not able to participate in a structured
exercise program are frequently able to achieve improved
circulation and joint mobility by stretching and by
exaggerating normal movements.
Data from Potter PA, Perry AG, Stocket PA, et al.: Fundamentals of nursing: Concepts, process, and practice, ed 8, St. Louis, 2013, Mosby.
Body Mechanics and Patient Mobility CHAPTER 8
USE OF APPROPRIATE BODY MECHANICS
Understanding of body mechanics (the area of physiology for the study of muscle action and how muscles
function in maintaining the posture of the body and
prevention of injury during activity) includes knowledge of how certain muscle groups are used. The nurse
uses body mechanics daily in making beds, assisting
the patient to walk, carrying supplies and equipment,
lifting, providing patient care, and carrying out other
procedures.
For prevention of injury to the nurse and the patient,
principles of body mechanics for health care workers
(Table 8-1) should be followed by all health care professionals and personnel. Patients should also be
taught principles of good body mechanics to protect
themselves. The appropriate use of body mechanics
should consistently be practiced in the workplace and
in one’s personal life so that MSDs do not occur. Maintenance of appropriate body alignment is the key
factor in proper body mechanics. The term alignment
refers to the relationship of various body parts to each
other. Alignment helps balance and helps coordinate
movements smoothly and effectively.
Maintenance of a wide base of support (a stance
with feet shoulder width apart) when standing is one
of the basic concepts of good body mechanics and
alignment that should be followed because it helps in
providing better stability (Figure 8-1). Better stability
prevents the nurse from losing proper balance while
carrying out patient care, which could result in strain
or injury to muscles.
Table 8-1
161
The skeletal muscles and the nervous system maintain equilibrium, or balance, which facilitates appropriate body alignment when lifting, bending, moving,
and performing other activities. Bending one’s knees
and hips before attempting these activities protects the
back from the stress and potential injury inherent in
the physical work of nursing. When stooping, the hips
and knees should be flexed or bent and appropriate
body alignment maintained (i.e., the back kept
Center of
gravity
Center of
gravity
Line of
gravity
Line of
gravity
Base of support
FIGURE 8-1 Good position for body mechanics: chin is high and
parallel to the floor, abdomen is tightened (internal girdle) in and up
with gluteal muscles tucked in, and feet are spread apart for a broad
base of support. (From Potter PA, Perry AG, Stocket PA, et al.:
Fundamentals of nursing: Concepts, process, and practice, ed 8,
St. Louis, 2013, Mosby.)
Body Mechanics for Health Care Workers
ACTION
When planning to move a patient, arrange for adequate
help. Use mechanical aids if help is unavailable.
RATIONALE
Two workers lifting together divide the workload by 50%.
Encourage patient to assist as much as possible.
This promotes patient’s abilities and strength while
keeping workload to a minimum.
Keep back, neck, pelvis, and feet aligned. Avoid twisting.
Twisting increases risk of injury.
Flex knees; keep feet shoulder length apart.
A broad base of support increases stability.
Position yourself close to patient (or object being lifted).
This minimizes strain and undue stress on the lifter.
Holding an object or patient away from the body
increases the workload.
Use arms and legs (not back).
The leg muscles are stronger larger muscles capable
of greater work without injury.
Slide patient toward yourself using a pull sheet.
Sliding requires less effort than lifting. Pull sheet keeps
to a minimum any shearing forces, which can damage
patient’s skin.
Set (tighten) abdominal and gluteal muscles in
preparation for move.
Preparing muscles for the load limits strain to the least
possible level.*
Person with the heaviest load coordinates efforts of team
involved by counting to 3.
Simultaneous lifting keeps the load for any one lifter to
a minimum.
*Back injuries are still the most common occupational injury among nurses.
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UNIT II Fundamentals of Clinical Practice
Box 8-1 Correct Use of Body Mechanics
Actions to promote proper body mechanics (Rationale):
• Position feet shoulder width apart. (Provides adequate
base of support.)
• Align and balance weight on both feet. (Distributes
weight evenly.)
• Flex knees slightly. (Prevents hyperextension [extreme or
abnormal stretching].)
• Tilt pelvis forward by pulling buttocks inward so gluteal
muscles are contracted in and down. (Helps straighten
the lumbar curve of the spine, increasing power and
reducing strain.)
• Contract abdominal muscles in and up. (Provides
support and reduces muscle strain.)
• Hold chest up. (Allows adequate lung expansion.)
• Keep head erect. (Helps maintain appropriate alignment
of the spine.)
• Use appropriate body mechanics in all activities:
standing, sitting, bending, and lifting. (Produces most
efficient body movement.)
• Face your work area. (Prevents unnecessary twisting.)
• Push, slide, or pull heavy objects. (Places less strain on
body than lifting does.)
• Lift twice—first mentally, and then physically. (Helps
determine whether assistance is needed.)
• Do not lift objects higher than chest level. Do not reach
above your shoulders. (Use of a step stool to reach an
object higher than chest level is much safer.)
injury. Knowing the maximum weight that is safe to
carry is also important. Many facilities suggest a 50-lb
weight limit on lifting for their staff.
Nurses should assess their own abilities and limitations and those of the person helping, if working in
pairs. Correct use of body mechanics is essential to providing efficient care while preventing injury (Box 8-1).
POSITIONING OF PATIENTS
FIGURE 8-2 Picking up a box with use of good body mechanics.
Box is carried close to the nurse’s body and base of support.
(From Sorrentino SA, Remmert LN: Mosby’s essentials for nursing
assistants, ed 5, St. Louis, 2014, Mosby.)
straight). Bending from the waist should be avoided
because this will, in time, strain the lower back
(Figure 8-2). The nurse should work at a height or level
that is comfortable to help prevent undue stress and
strain on the back muscles. This can be easily accomplished by adjusting the height of the bed to a level
appropriate for the nurse’s height.
Use of large muscle groups (such as arm and shoulder muscles, hips, and thigh muscles) helps in performing a bigger workload more safely. The more
muscle groups used, the more evenly the workload is
distributed. If the base of support is widened in the
direction of movement, less effort is needed to carry
out an activity. To avoid twisting the spine, the nurse
should stand directly in front of the person or object
being worked with.
Nurses have numerous other ways to protect themselves and the patient from injury. Carrying objects
close to the midline of the body (see Figure 8-2), avoiding reaching too far, avoiding lifting when other means
of movement are available (such as sliding, rolling,
pushing, or pulling), using devices instead of or in
combination with lifting, and using alternating periods
of rest and activity are just a few of the ways to prevent
Positioning of patients is a common intervention performed by nursing personnel. Many positions can be
used to prevent patients from development of complications (Skill 8-1; see the Patient Teaching box on
mobility). Inappropriate positioning poses the risk of
causing permanent disability.
Patient Teaching
Mobility
• Instruct the patient and the family on proper mobility
techniques.
• Teach the patient ways to assist with positioning.
• Provide the opportunity for return demonstration.
• Teach the patient and the family signs and symptoms of
skin impairment and contractures.
• Teach the patient to avoid prolonged sitting. Frequent
stretching decreases joint and muscle contractures.
• Teach the importance of maintaining skin integrity.
• Explain the importance of proper body alignment.
• Explain the importance of rising slowly from lying to
sitting, from sitting to standing, and after stooping
(prevents orthostatic hypotension).
• Provide time for questions and answers.
• Emphasize the importance of the patient performing
active range-of-motion (ROM) exercises when possible.
• If the patient’s height prevents the feet from touching the
floor when sitting, teach the patient to rest feet on a
footstool.
• For prevention of thrombophlebitis, teach patients not to
cross their legs when sitting and to avoid prolonged
immobility. Teach those at increased risk the signs and
symptoms of thrombophlebitis.
Body Mechanics and Patient Mobility CHAPTER 8
Skill 8-1
163
Positioning Patients
NURSING ACTION (RATIONALE)
1. Assess patient’s body alignment and comfort
level while patient is lying down. (Provides
baseline data concerning body alignment and comfort
level. Helps determine ways to improve position and
alignment.)
2. Assemble equipment and supplies. (Organizes
procedure.)
• Pillows
• Footboard
• Trochanter roll
• Splinting devices
• Hand rolls
• Safety reminder devices
• Side rails
3. Request assistance as needed. (Provides for safety.)
4. Introduce self. (Decreases patient’s anxiety.)
5. Identify patient. (Ensures procedure is performed
with correct patient.)
6. Explain procedure. (Enlists cooperation from patient
and decreases patient anxiety.)
7. Perform hand hygiene. Wear gloves as necessary
according to agency policy and guidelines from
the Centers for Disease Control and Prevention
(CDC) and Occupational Safety and Health
Administration (OSHA). (Reduces spread of
microorganisms.)
8. Prepare patient. (Prepares for procedure.)
a. Close door or pull curtain. (Provides privacy.)
b. Raise level of bed to comfortable working
height. (Promotes good body mechanics in the
nurse and safety for the patient.)
c. Remove pillows and devices used in previous
position. (Makes access to patient easier.)
d. Put bed in flat position, or as low as patient
can tolerate, and lower side rail closest to you.
(Facilitates procedure.)
9. Position patient.
a. Dorsal (supine) position (lying flat on the
back; see illustration).
(1) Place patient on back with head of bed flat.
(Necessary for placing patient in supine
position.)
(2) Place small rolled towel under lumbar
area of back. (Provides support for lumbar
spine.)
(3) Place pillow under upper shoulder, neck,
and head. (Maintains correct alignment and
prevents flexion contractures of cervical lumbar
spine.)
(4) Place trochanter rolls parallel to lateral
surface of thighs. (Reduces external rotation
of hip.)
(5) Place small pillow or roll under ankle
to elevate heels. (Reduces pressure on heels,
helping to prevent skin impairment.)
(6) Support feet in dorsiflexion with firm
pillow, footboard, or high-top sneakers.
(Prevents foot drop.)
(7) Place pillows under pronated forearms,
keeping upper arms parallel to patient’s
body (see illustration). (Reduces internal
rotation of shoulder and prevents extension
of elbows. Maintains correct body alignment.)
(8) Place hand rolls in patient’s hands.
(Reduces extension of fingers and abduction
of thumb.)
Step 9a
b. Dorsal recumbent position (supine position
with patient lying on back, head, and shoulder
with extremities moderately flexed; legs are
sometimes extended).
(1) Move patient and mattress to head of bed.
(Ensures appropriate body alignment.)
(2) Turn patient onto back. (Appropriately
positions patient.)
(3) Assist patient to raise legs, bend knees,
and allow legs to relax. (Puts patient in
dorsal recumbent position.)
(4) Replace pillow. Patient sometimes needs a
small lumbar pillow. (Provides comfort.)
c. Fowler’s position (posture assumed by patient
when head of bed is raised 45 to 60 degrees;
see illustration).
(1) Move patient and mattress to head of bed.
(Ensures appropriate body alignment.)
(2) Raise head of bed to 45 to 60 degrees.
(Positions patient appropriately.)
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UNIT II Fundamentals of Clinical Practice
Skill 8-1
Positioning Patients—cont’d
(3) Replace pillow. (Provides comfort, maintains
proper body alignment, and ensures skin
integrity.)
(4) Use footboard or firm pillow. (Prevents
patient from slipping down in bed.)
(5) Use pillows to support arms and hands.
(Provides comfort and maintains correct
alignment.)
(6) Place small pillow or roll under ankles.
(Reduces risk of skin impairment over heels.)
Step 9c
d. Semi-Fowler position (posture assumed by
patient when head of bed is raised
approximately 30 degrees).
(1) Move patient and mattress to head of bed.
(Ensures appropriate body alignment.)
(2) Raise head of bed to about 30 degrees.
(Positions patient appropriately.)
(3) Replace pillow. (Provides patient comfort.)
See suggestions in Step 9c for positioning
of pillows.
e. Orthopneic position (the posture assumed by
the patient sitting up in bed at 90-degree
angle, or sometimes resting in forward tilt
while supported by pillow on overbed table;
see illustration). Often used for the patient
with a cardiac or respiratory condition.
(1) Elevate head of bed to 90 degrees.
(Facilitates positioning.) Patient sometimes
sits on side of bed with legs dangling or
propped on a chair.
(2) Place pillow between patient’s back and
mattress. (Provides back support.)
(3) Place pillow on overbed table and assist
patient to lean over, placing head on
pillow. (Facilitates ease of breathing. Women
are more comfortable with arms on pillow and
head on arms.)
f. Sims position (position in which patient lies
on side with knee and thigh drawn upward
toward chest; see illustration). The left Sims
position is appropriate positioning for the
enema procedure and administration of a
rectal suppository.
(1) Place patient in supine position. (Prepares
patient for position.)
(2) Position patient in lateral position, lying
partially on the abdomen. (Patient is rolled
only partially on abdomen.)
(3) Draw knee and thigh up near abdomen
and support with pillows. (Positions patient
appropriately.)
(4) Place patient’s lower arm along the back.
(Provides appropriate body alignment.)
(5) Bring upper arm up, flex elbow, and
support with pillow. (Provides comfort and
decreases strain on joints.)
(6) Allow patient to lean forward to rest on
chest. (Provides maximum comfort.)
Step 9f
g. Prone position (lying face down in horizontal
position; see illustration).
(1) Assist patient onto abdomen with face to
one side. (Facilitates positioning.)
(2) Flex arms toward the head. (Provides
appropriate body alignment.)
(3) Position pillows for comfort. Place a pillow
under lower leg to release any “pull” on
the lower back, or place a pillow under the
head as shown (or both). (Increases comfort
and maintains proper body alignment.)
Step 9g
Step 9e
h. Knee-chest (genupectoral) position (patient
kneels so that weight of body is supported by
knees and chest, with abdomen raised, head
turned to one side, and arms flexed; see
illustration).
Body Mechanics and Patient Mobility CHAPTER 8
Skill 8-1
165
Positioning Patients—cont’d
(1) Turn patient onto abdomen. (Facilitates
positioning.)
(2) Assist patient into kneeling position; arms
and head rest on pillow while upper chest
rests on bed. (Allows for as much comfort as
possible in this position.)
chest injury.) Trendelenburg’s position was
once used in the treatment for shock but is
not used as frequently to treat shock
because it causes pressure on the
diaphragm by organs in the abdomen and
shunts more blood to the brain rather than
all of the vital organs. Trendelenburg’s
position is sometimes used to assist in
venous distention during central line
placement.
Step 9h
i. Lithotomy position (patient lies supine with
hips and knees flexed and thighs abducted
and rotated externally [sometimes feet are
positioned in stirrups]; see illustration).
(1) Position patient to lie supine (lying on the
back). (Facilitates positioning.)
(2) Request patient to slide buttocks to edge of
examining table. (Facilitates positioning.)
(3) Lift both legs; have patient bend knees and
place feet in stirrups. (Positions patient
appropriately.)
(4) Drape patient. (Provides privacy.)
(5) Provide small lumbar pillow if desired.
(Provides comfort. Pillow under head also
provides comfort.)
Step 9i
j. Trendelenburg’s position (patient’s head is
low and the body and legs are on inclined
plane; see illustration).
(1) Place patient’s head lower than body, with
body and legs elevated and on an incline.
Foot of bed is sometimes elevated on
blocks. (Not used if patient has a head or
Step 9j
k. Lateral position (see Chapter 18).
10. Assess patient for the following: (Provides
follow-up with appropriate nursing interventions.)
• Proper body alignment. Small children often
need to be propped with pillows to help them
maintain a position.
• Comfort. Performing a back massage after
turning from one position to another helps
prevent impaired skin integrity.
• Skin integrity. Skin of older adults is often thin,
lacks elasticity, and needs special care to
prevent tearing and further impaired skin
integrity.
• Breathing. Additional support is necessary in
some positions if patient finds ease of
respiratory effort difficult to maintain.
• Tolerance of position. Ongoing observations
regarding patient’s activity tolerance is
provided, and complications of immobility are
indicated.
• Repositioning. Reposition debilitated,
unconscious, or paralyzed patients at least
every 2 hours.
11. Perform hand hygiene. (Reduces spread of
microorganisms.)
12. Document. (Records procedure, patient’s response,
and effectiveness of nursing interventions.)
• Procedure
• Observations (e.g., skin condition, joint
movement, patient’s ability to assist with
positioning)
• Patient teaching (see Patient Teaching and
Home Care Considerations boxes).
Step 9a, 9g, and 9h figures from Potter PA, Perry AG: Basic nursing: Essentials for practice, ed 6, St. Louis, 2006, Mosby.
Step 9f figure from Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed 4, St. Louis, 2008, Mosby.
Step 9i figure from Seidel HM, Benedict GW, Dains JE, et al.: Mosby’s guide to physical examination, ed 6, St. Louis, 2006, Mosby.
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UNIT II Fundamentals of Clinical Practice
MOBILITY VERSUS IMMOBILITY
Mobility is a person’s ability to move around freely in
his or her environment. Moving about serves many
purposes, including exercising, expressing emotion,
attaining basic needs, performing recreational activities, and completing activities of daily living (ADLs;
those activities of physical self-care such as bathing,
dressing, and eating). In addition, mobility is fundamental to maintaining the body’s normal physiologic
activities. For normal physical mobility, the body’s
nervous, muscular, and skeletal systems must be
intact, functioning, and used regularly. Although a
person may welcome a rare day to lie in bed and rest,
the person who is immobile (experiencing immobility,
the inability to move around freely) is predisposed to
a wide variety of complications (Box 8-2).
Many types of health problems potentially lead to
a decline in a patient’s mobility. Patients with certain
illnesses, injuries, or surgeries sometimes experience
a period of immobilization as a result of changes in
medical and physical status. In some cases, immobilization is also used therapeutically to limit the movement of the whole body or a body part, and some
patients are under ambulation restrictions.
Interventions to prevent complications of immobility are varied, and many do not require a physician’s
order (see Box 8-2).
Various assistive devices may be used to maintain
correct body positioning and to help prevent complica-
tions that commonly arise when a patient needs prolonged bed rest (Table 8-2). Several of the devices are
especially useful in the care of patients who have a loss
of sensation, mobility, or consciousness (Figures 8-3
to 8-5).
NEUROVASCULAR FUNCTION
One of the responsibilities of the nurse is frequent
monitoring of the patient’s neurovascular function, or
circulation, movement, and sensation (CMS) assessment. The LPN/LVN checks for skin color, temperature, movement, sensation, pulses, capillary refill, and
pain. The affected limb should be compared with the
unaffected one (Table 8-3).
This assessment is especially important when
compression from external devices, such as casts and
bulky dressings, creates the risk of acute compartment
syndrome, which has the potential to cause extensive
tissue damage. Acute compartment syndrome occurs
in the extremities, especially the legs, where a sheath
of inelastic fascia partitions blood vessel, nerve,
and muscle tissue. Normally, the pressure in this compartment is less than capillary pressure. However,
compression created by external pressure or the accumulation of excessive tissue fluid from severe burns,
fractures, crushing injuries, or severely bruised muscles
increases compartmental pressure and in some cases
leads to compartment syndrome. Ischemic tissue necrosis is likely to occur within 4 to 8 hours unless this
Box 8-2 Complications of Immobility and Preventive Measures
COMPLICATIONS
• Muscle atrophy and asthenia (muscle weakness):
Muscles decrease in size and strength when not
continually used.
• Contractures: When muscles, ligaments, and tendons
are not shortened and lengthened with movement, a
permanent shortening of these structures may occur.
• Disuse osteoporosis: Lack of weight bearing on bones
causes bone demineralization, allowing fractures to
occur more easily.
• Pressure ulcer: Tissue ischemia (lack of blood flow to
an area) from unrelieved pressure results in skin
breakdown.
• Constipation: Immobility slows peristalsis, resulting
in stool remaining in the colon longer and muscle
atrophy in the abdominal muscles that aid in expulsion
of stool.
• Urinary tract infection: Urinary stasis causes changes in
pH and allows bacterial growth.
• Renal calculi (kidney stones): Urinary stasis from
immobility leads to slowed calcium metabolism, thus
leading to stone formation.
• Hypostatic pneumonia: Decreased aeration and
accumulation of secretions lead to inflammation and
infection in the lungs.
• Orthostatic hypotension (drop in systolic blood pressure
of 20 mm Hg or a decrease of 10 mm Hg in diastolic
blood pressure within 3 minutes of standing when
moving from lying or sitting to standing position):
Immobility can lead to a decrease in venous return or
decreased cardiac output in response to postural
change.
• Anorexia (decreased appetite): Lack of mobility slows
the digestive process and slows the metabolic rate,
causing decreased appetite.
• Insomnia: Decreased stimuli, depression, and frequent
napping during the day as a result of immobility may
cause difficulty sleeping at night.
• Disorientation: Lack of stimulation, decreased endorphin
production, decreased need for thought processes, and
decreased socialization may lead to disorientation.
• Thrombophlebitis and deep vein thrombosis (DVT; blood
clot with accompanying inflammation of the involved
vein, usually of the lower extremity): Decrease in venous
circulation allows blood to pool in lower extremities,
leading to inflammation of vessels and clot formation.
• Pulmonary embolism (blood clot that has traveled
to the lungs): DVT that has broken loose from vessel
and has traveled to the lungs, causing a blockage in
a pulmonary vessel.
Body Mechanics and Patient Mobility CHAPTER 8
Box 8-2
167
Complications of Immobility and Preventive Measures—cont’d
INTERVENTIONS
• Reposition at least every 2 hours
• Ensure adequate intake; encourage fluids
• Encourage a well-balanced diet
• Prevent deformities (e.g., footboard or other measures
to prevent foot drop)
• Handle and transfer patients carefully; maintain proper
body alignment
• Position lower extremities properly (a pillow or wedge
between the legs, never under knees)
• Early ambulation
• Antiembolism measures (thromboembolic deterrent
[TED] hose or decompression boots)
• Progressive ambulation
• Roll up head of bed
• Dangle over side of bed
• Stand
• Take a few steps
• Sit in the chair
• Up to bathroom
• Up and about the room
• Up and out in the hallway
• Up as desired
DURING AMBULATION
1. Observe the patient closely.
2. Encourage the patient to do the following:
• Take slow, deep breaths
• Keep eyes open and look straight ahead
• Keep head up
(These measures aid in preventing vertigo, syncope,
weakness, and nausea and vomiting.)
3. If the patient starts to fall, do not attempt to prevent
the fall. Ease the patient to the floor. This allows you
to break the fall, control its direction, and also protect
May support the falling patient under the
arms as shown.
the patient’s head. Follow these steps when assisting
a patient’s fall:
• Stand with your feet apart. Keep your back straight.
• Bring the patient close to your body as quickly as
possible. Use the gait belt if one is worn. If not, wrap
your arms around the patient’s waist. Move your leg
so the patient’s buttocks rest on it. Move the leg
near the patient (see illustration).
• Lower the patient to the floor by letting the patient
slide down your leg. Bend at your hips and knees
as you lower the patient (see illustration). (The
gravitational pull enables the patient to be lowered
to the floor with a minimal amount of strain to your
musculoskeletal system.)
• Call for assistance.
• Assist patient to return to bed.
• Report and document the following:
• How the fall occurred
• How far the patient walked
• How activity was tolerated before the fall
• Any report of symptoms before the fall
• The amount of assistance needed by the patient
while walking
• Complete an incident report, if required. (Know
agency policy.)
4. On a daily basis encourage the following:
• Deep breathing and coughing exercises (spirometry)
• Careful use of medications
5. Be certain to provide the following:
• Suitable diversion
• Meticulous skin care
• Range-of-motion exercises
• Reality therapy
The patient’s buttocks rest on your leg.
Slide the patient down your leg to
the floor.
168
UNIT II Fundamentals of Clinical Practice
Table 8-2
Assistive Devices for Proper Positioning
DEVICE
Pillow
REASON FOR USE
Provides support of body or extremity; elevates body part; splints incisional area to
reduce postoperative pain during activity or coughing and deep breathing
Foot boots or foot boards
Maintain feet in dorsiflexion, which prevents plantar flexion (foot drop)
Trochanter roll (see Figure 8-3)
Prevents external rotation of legs when patient is in supine position; possible to make
with a bath blanket
Sandbag
Provides support and shape to body contours; immobilizes extremity; maintains
specific body alignment
Hand roll (see Figure 8-4)
Maintains thumb slightly adducted and in opposition to fingers; maintains fingers in
slightly flexed position
Hand-wrist splint
Individually molded for patient to maintain proper alignment of thumb; slightly adducted
in opposition to fingers; maintains wrist in slight dorsiflexion
Trapeze bar (see Figure 8-5)
Enables patient to raise trunk from bed; enables patient to transfer from bed to
wheelchair; allows patient to perform exercises that strengthen upper arms
Side rail
Helps weak patient to roll from side to side or to sit up in bed
Bed board
Provides additional support to mattress and improves vertebral alignment
Wedge pillow
Also called abductor pillow (triangular pillow made of heavy foam); used to maintain the
legs in abduction after total hip replacement surgery
Modified from Potter PA, Perry AG, Stocket PA: Basic nursing: Essentials for practice, ed 7, St. Louis, 2011, Mosby.
FIGURE 8-3 Trochanter roll. (From Potter PA, Perry AG, Stocket PA,
et al.: Basic nursing Essentials for practice, ed 7, St. Louis, 2011,
Mosby.)
FIGURE 8-5 Patient using a trapeze bar. (From Potter PA, Perry AG,
Stocket PA, et al.: Basic nursing, ed 7, St. Louis, 2011, Mosby.)
FIGURE 8-4 Hand roll. (From Potter PA, Perry AG, Stocket PA, et al.:
Basic nursing, ed 7, St. Louis, 2011, Mosby.)
pressure is relieved and compartment syndrome
reversed (American Academy of Orthopaedic Surgeons, 2009).
Symptoms of acute compartment syndrome include
pain within the muscle, especially when stretched, that
is more intense than expected from the injury or causative factor; tingling and burning or a feeling of pins
and needles in the affected area (paresthesias); and a
full or tight feeling in the muscle. Numbness and
paralysis are late signs of compartment syndrome and
may be indicative of permanent damage.
Body Mechanics and Patient Mobility CHAPTER 8
169
Table 8-3 Assessment of Neurovascular Status
CHARACTERISTIC
Skin color
ASSESSMENT TECHNIQUE
Inspect the color of the skin distal to the injury.
NORMAL FINDINGS
The skin color should match that of the
unaffected body part.
Skin temperature
Palpate the area distal to the injury to determine
whether any change in skin temperature has
occurred compared with other body parts.
The skin is warm to the touch.
Movement
Ask the patient to move the affected area or the
area distal to the injury, unless contraindicated.
The patient is able to move with minimal
difficulty and with minimal, if any, discomfort.
Move the area distal to the injury if the patient is
unable to move the body part on his or her own.
No difference in comfort is found compared with
the patient actively moving the body part.
Ask the patient if numbness or tingling is present
(paresthesia), and assess with proper devices as
necessary, such as a cotton-tipped applicator or
tongue blade.
No numbness or tingling occurs; no difference in
sensation is seen in the affected and
unaffected body parts.
Assess sensation with a cotton-tipped applicator,
tongue blade, or other device as indicated.
Loss of sensation may indicate nerve or
circulatory impairment.
Pulses
Palpate the pulses distal to the site of injury.
Pulses are strong and easily palpated; no
difference is found in the affected and
unaffected extremities.
Capillary refill
Press the nail beds distal to the injury until
blanching occurs (or until the skin near the nail
blanches, if nails are thick and brittle); pressure
should be applied for approximately 3 to 5 sec.
Blood returns (return to usual color) within 3 sec
(5 sec for older adult patients).
Pain
Ask the patient about the location, the nature, and
the frequency of pain and to rate the pain with a
pain scale.
The patient should have no or minimal reports of
pain.
Sensation
Acute compartment syndrome is an emergency
situation. The earlier compartment syndrome is
treated, the better the prognosis. If acute compartment
syndrome is caused by an external device, such as a
cast or tight bandage, the pressure should be removed
immediately by cutting away these devices. If the syndrome is caused by other factors, surgical intervention
may be required. A fasciotomy may be necessary, in
which the surgeon makes an incision into the skin and
fascia to release the pressure. This incision is sometimes left open until swelling subsides.
Chronic compartment syndrome is not an emergency situation and is usually caused by exercise that
involves repetitive movement, such as bicycling or
running. The symptoms include pain and cramping
during exercise, visible muscle bulging, and numbness. These symptoms are usually alleviated by discontinuing the activity and by rest.
PERFORMANCE OF RANGE-OF-MOTION EXERCISES
Regardless of whether the causes of immobility are
permanent or temporary, the immobilized patient
needs some type of exercise to prevent excessive
muscle atrophy and joint contracture. The nurse and
other health care personnel, including members of the
physical therapy department, help the patient with
decreased mobility to perform range-of-motion (ROM;
movement of the body that involves the muscles and
joints in natural directional movements) exercises.
Passive ROM exercise is performed by caregivers, and
active ROM by patients. The designated joint (any
one of the connections between bones) is moved
actively or passively to the point of resistance or
pain, with avoidance of injury. ROM exercises are
increased with subsequent exercises as tolerated (Table
8-4; Skill 8-2).
Some patients who are weak or partially paralyzed
are able to move a limb partially through ROM and
the nurse may then assist the patient to finish the
full ROM. This is referred to as passive assisted ROM.
Active assisted ROM occurs when the patient uses the
strong arm to exercise the weaker or paralyzed arm.
The LPN/LVN best meets the needs of the patient
by encouraging the patient to be as independent as
possible.
Assessment by the nurse and the physical therapy
department determines the patient’s current mobility
status. The patient who is able to move about freely
independently performs ADLs and active ROM exercises. Patients who are partially immobile or unable to
move about freely (from paraplegia, quadriplegia,
weakness, or fatigue) need the nurse and other health
care personnel to assist with passive ROM exercises.
170
UNIT II Fundamentals of Clinical Practice
Table 8-4
BODY PART
Neck and
cervical
spine
Joint Range-of-Motion Exercises
TYPE OF JOINT
Pivotal
TYPE OF MOVEMENT
Flexion:* Bring
chin to rest on
chest.
Extension:† Return
head to erect
position.
Hyperextension:‡
Bend head back
as far as
possible.
Use caution with
older adults.
BODY PART
TYPE OF JOINT
Shoulder—cont'd
Internal rotation:
With elbow
flexed, rotate
shoulder by
moving arm until
thumb is turned
inward and
toward back.
External rotation:
With elbow
flexed, move
arm until thumb
is upward and
lateral to head.
Lateral flexion: Tilt
head as far as
possible toward
each shoulder.
Circumduction:
Move arm in full
circle.
(Circumduction
is combination
of all
movements of
ball-and-socket
joint.)
Rotation: Turn
head as far as
possible to right
and left.
Shoulder
Ball and socket
Flexion: Raise arm
from side
position forward
to position
above head.
Extension: Return
arm to position
at side of body.
Hyperextension:
Move arm
behind body,
keeping elbow
straight.
Abduction:§ Raise
arm to side to
position above
head with palm
away from
head.
Adduction:‖ Lower
arm sideways
and across
body as far as
possible.
TYPE OF MOVEMENT
Elbow
Hinge
Flexion: Bend
elbow so that
lower arm
moves toward
its shoulder joint
and hand is
level with
shoulder.
Extension:
Straighten
elbow by
lowering hand.
Hyperextension:
Bend lower arm
back as far as
possible.
Forearm
Pivotal
Supination:¶ Turn
lower arm and
hand so that
palm is up.
Pronation:# Turn
lower arm so
that palm is
down.
*Flexion: Movement of certain joints that decreases angle between two adjoining bones.
†Extension: Movement of certain joints that increases angle between two adjoining bones.
‡Hyperextension: Extreme or abnormal extension.
§Abduction: Movement of limb away from body.
‖Adduction: Movement of limb toward axis of body.
¶Supination: Kind of rotation that allows palm of hand to turn up.
# Pronation: Palm of hand turned down.
Body Mechanics and Patient Mobility CHAPTER 8
171
Table 8-4 Joint Range-of-Motion Exercises—Cont’d
BODY PART
Wrist
Fingers
TYPE OF JOINT
Condyloid
Condyloid hinge
TYPE OF MOVEMENT
Flexion: Move
palm toward
inner aspect of
forearm.
Extension: Move
fingers so that
fingers, hands,
and forearm are
in same plane,
in a straight line.
Hyperextension:
Bring dorsal
surface of hand
back as far as
possible.
Radial flexion:
Bend wrist
medially toward
thumb.
Ulnar flexion: Bend
wrist laterally
toward fifth
finger.
BODY PART
Hip
TYPE OF JOINT
Ball and socket
Hyperextension:
Move leg behind
body.
Abduction: Move
leg laterally
away from body.
Adduction: Move
leg back toward
medial position
and beyond if
possible.
Flexion: Make fist.
Extension:
Straighten
fingers.
Hyperextension:
Bend fingers
back as far as
possible.
Internal rotation:
Turn foot and
leg toward other
leg.
External rotation:
Turn foot and
leg away from
other leg.
Abduction: Spread
fingers apart.
Adduction: Bring
fingers together.
Thumb
Saddle
Flexion: Move
thumb across
palmar surface
of hand.
Extension: Move
thumb straight
away from
hand.
Abduction: Extend
thumb laterally
(usually done
when placing
fingers in
abduction and
adduction).
Adduction: Move
thumb back
toward hand.
Opposition: Touch
thumb to each
finger of same
hand.
TYPE OF MOVEMENT
Flexion: Move leg
forward and up
with knee in
extension.
Extension: Move
leg back beside
other leg while
knee joint
remains in
extension.
Circumduction:
Move leg in
circle.
Knee
Hinge
Flexion: Bring heel
back toward
back of thigh.
Extension: Return
heel to floor.
Continued
172
UNIT II Fundamentals of Clinical Practice
Table 8-4 Joint Range-of-Motion Exercises—Cont’d
BODY PART
Ankle
Foot
TYPE OF JOINT
Hinge
Gliding
TYPE OF MOVEMENT
Dorsiflexion:**
Move foot so
that toes are
pointed upward.
Plantar flexion:
Move foot so
that toes are
pointed
downward.
BODY PART
Toes
TYPE OF JOINT
Condyloid hinge
TYPE OF MOVEMENT
Flexion: Curl toes
downward.
Extension:
Straighten toes.
Abduction: Spread
toes apart.
Adduction: Bring
toes together.
Inversion: Turn
sole of foot
medially.
Eversion: Turn sole
of foot laterally.
Figures from Potter PA, Perry AG: Fundamentals of nursing: Concepts, process, and practice, ed 6, St. Louis, 2006, Mosby.
**Dorsiflexion: To bend or flex backward.
Modified from Potter PA, Perry AG: Basic nursing: Essentials for practice, ed 7, St. Louis, 2012, Mosby.
Lifespan Considerations
Older Adults
Range-of-Motion Exercises
• Some older adults who have chronic illnesses need to
separate range-of-motion (ROM) exercises into two or
more sessions to control fatigue.
• Inadequate intake of calcium or exposure to sunlight
increases older adults’ risk of bone loss and increases the
need for ROM and weight-bearing exercise.
• Older people who fear falling often display reluctance to
move about freely. Encouragement, reassurance, and
assistance from family members and caregivers decrease
anxiety.
• Older adult patients who are depressed often prefer to
stay in bed, especially when they were accustomed to
being very independent and active and now need
assistance.
• Many older adults with arthritis require additional time in
the morning before resuming activities.
• Even without arthritis, older adults often need more time
in the morning to resume activity.
Encourage and assess active ROM every day (see
Life Span Considerations for Older Adults box). The
total amount of activity required to prevent physical
disuse syndrome (a state in which an individual is at
risk for deterioration of body systems as the result of
prescribed or unavoidable inactivity) is only about 2
hours for every 24-hour period. Schedule this activity
throughout the day to prevent the patient from remaining inactive for long periods (Ackley, 2011).
CONTINUOUS PASSIVE MOTION MACHINES
Continuous passive motion (CPM) machines flex and
extend joints for passive mobilization without the
FIGURE 8-6 Continuous passive movement (CPM) machine. (From
Perry AG, Potter PA, Elkin MK: Nursing interventions and clinical
skills, ed 5, St Louis, 2012, Mosby.)
strain of active exercises (Figure 8-6). This therapy is
frequently used immediately after total knee replacement surgery (knee arthroplasty) but can also be used
in outpatient or home physical therapy programs. The
CPM machine must be set according to the health care
provider ’s orders for the degree and the speed of flexion
and extension for each individual patient to prevent
damage to the joint or surgical site. Some recent studies
question the necessity of CPM machines and encourage
the use of immediate physical therapy instead.
CPM machines can be used on joints other than the
knee, including the hip, the shoulder, and the ankle.
Mobilization of the joint prevents complications, such
as joint contracture, atrophy of surrounding muscles,
and thromboembolism. With use of a CPM machine,
consider the following (Perry et al., 2012):
Body Mechanics and Patient Mobility CHAPTER 8
Skill 8-2
173
Performing Range-of-Motion Exercises
9. Begin by doing exercises in normal sequence
(see Table 8-4). Repeat each full sequence 5 times
during the exercise period. (Exercises are easiest to
perform in head-to-toe manner.) Discontinue
exercise if patient reports pain or if resistance or
muscle spasm occurs.
10. Assist patient by putting each joint through full
range of motion (see Table 8-4). (Provides baseline
for joint movement.)
11. Position patient for comfort. To prevent
contracture (an abnormal shortening of a
muscle), do not allow patients with joint pain to
remain continuously in position of comfort; joints
must be exercised routinely. (Immobility
contributes to contractures.) Periodically provide
back massage. (Provides comfort.)
12. Adjust bed linen. (Provides comfort and privacy.)
13. Remove and dispose of gloves and wash hands.
(Reduces spread of microorganisms.)
14. Document the following: (Records procedure and
patient’s response.)
• Joints exercised
• Presence of edema or pressure areas
• Any discomfort resulting from the exercises
• Any limitations of ROM
• Patient’s tolerance of the exercises
• Patient teaching (see Patient Teaching box
Home Care Considerations boxes)
NURSING ACTION (RATIONALE)
1. Refer to medical record or care plan for special
interventions. (Provides basis for care.)
2. Assemble equipment. (Organizes procedure.)
• Clean gloves, if necessary (see step 6).
3. Introduce self. (Decreases patient’s anxiety.)
4. Identify patient. (Ensures procedure is performed
with correct patient.)
5. Explain procedure. (Enlists cooperation and
decreases patient’s anxiety.)
6. Perform hand hygiene and don clean gloves
according to agency policy and guidelines from
CDC and OSHA. (Reduces spread of
microorganisms.)
7. Prepare patient for intervention:
a. Close door to room or pull curtain. (Provides
privacy.)
b. Drape for procedure if appropriate. (Prevents
unnecessary exposure of patient.)
c. Raise bed to comfortable working level.
(Promotes good body mechanics in the nurse and
safety for the patient.)
d. Assist patient to a comfortable position, either
sitting or lying down. (Ensures patient’s comfort.)
e. Medicate patient as needed for pain. (Promotes
patient comfort.)
8. Support the body part above (proximal to) and
below (distal to) the joint by cradling the
extremity or by using cupped hand to support
the joint being exercised. (Protects the weaker joints
and muscles.)
Step 8
Step 8 figure from Elkin MK, Perry AG, Potter PA: Nursing interventions and clinical skills, ed 4, St. Louis, 2008, Mosby.
174
UNIT II Fundamentals of Clinical Practice
• Older adults who need CPM therapy after discharge
sometimes must enter a rehabilitation facility or
have home care because the equipment is not easy
to manipulate.
• Older adults with fragile skin are at a high risk of
skin impairment from pressure of the CPM machine.
Closely monitor pressure point areas such as the
heel.
• Physical therapy is frequently used in addition to
the CPM therapy.
• If the patient is using CPM at home, ensure that the
patient and the family members assisting with care
are given instructions on use of the CPM machine,
prescribed settings, and parameters for contacting
the physician.
• The goals of CPM therapy are to increase or maintain physical mobility by improving joint range of
motion and to prevent skin breakdown at pressure
points.
Skill 8-3
• Care of the patient during CPM therapy can be delegated to assistive personnel, but assessment of the
patient must not be. Assessment remains a nursing
responsibility.
MOVING THE PATIENT
A common nursing action is assisting patients in movement. Patients may need assistance in various ways,
such as moving the patient up in bed, out of bed, or
from a chair or wheelchair; turning the patient; and
assisting the patient in and out of the bed for ambulation (Skill 8-3). For some situations, the nurse uses
mechanical equipment for lifting patients, such as
the hydraulic lift, roller board, and gurney lift. The
nurse should first mentally think through the lift in an
effort to be prepared for lifting the patient and then
physically perform the lift. The nurse must ensure that
Text continued on p.179
Moving the Patient
NURSING ACTION (RATIONALE)
1. Refer to the medical record or care plan for
special interventions. (Provides basis for care.)
2. Assemble equipment. (Organizes procedure.)
• Hospital bed
• Chair
• Side rails
• Patient’s slippers
• Cotton blanket
• Pillows
• Extra personnel
• Lifting devices (see Skill 8-4)
3. Introduce self. (Decreases patient’s anxiety.)
4. Identify patient. (Ensures procedure is performed
with correct patient.)
5. Explain procedure. (Enlists cooperation and
assistance from patient and decreases patient’s
anxiety.)
6. Perform hand hygiene. (Reduces spread of
microorganisms.)
7. Prepare patient for interventions.
a. Close door or pull curtain. (Provides privacy.)
b. Adjust bed level for safe working height.
(Promotes good body mechanics in the nurse and
safety for the patient.)
c. Medicate patient as needed. (Promotes patient
comfort.)
8. Arrange for assistance as necessary. (Provides for
safety.)
9. Lift and move patient up in bed
(sometimes requires one nurse and sometimes
more):
a. Place patient supine with head flat. (Creates
less resistance on flat surface.)
b. Face the patient and establish base of support.
(Protects your back.)
c. Use a lift (draw) sheet to assist patient up in
bed. (Supports patient, assists staff, and prevents
shearing of patient’s skin.)
(1) Roll patient first to one side and then the
other, placing lift sheet underneath patient
from shoulders to thighs. (Facilitates the
position change.)
(2) Flex knees and face body in the direction
of the move. The foot farthest away from
the bed faces forward for broader base of
support.
(3) With one nurse on each side of patient,
grasp lift sheet firmly with hands near
patient’s upper arms and hips, rolling
the sheet material until hands are close
to the patient. (The closer the nurse is to
the patient, the less the nurse needs to raise
the patient up to clear the bed during the
move.)
Body Mechanics and Patient Mobility CHAPTER 8
175
Skill 8-3 Moving the Patient—cont’d
(4) Instruct patient to rest arms over body and
to lift head on the count of 3; at the same
time, pull the sheet to move the patient up
to head of bed.
11. Dangling patient:
a. Assess pulse and respirations. (Provides baseline
for assessing patient’s response to dangling.)
b. Move patient to side of bed toward the nurse.
(Makes it easier for patient to sit up. Request
patient do by self if possible.)
c. Lower bed to lowest position. (Provides patient
safety when getting up.)
d. Raise head of bed. (Patient can swing around
more easily to sitting position.)
e. Support patient’s shoulders and help to swing
legs around and off bed; do this all in one
motion by simply pivoting patient. Ensure
patient’s feet touch floor. (Prevents strain
on patient, especially if patient has an
incision.)
Step 9c(4)
A lift sheet is used to move the patient up in bed. The lift sheet
extends from the patient’s head to above the knees. The lift sheet is
rolled close to the patient and held near the shoulders and buttocks.
10. Turning the patient:
a. Stand with feet slightly apart and flex knees.
(Provides base of support.)
b. If the patient is unable to assist in turning, two
people should use the lift sheet to turn the
patient. (Provides patient safety and support and
protects the back of the persons assisting with the
turn.)
c. Move patient’s body to one side of the bed.
(Allows room for the patient to turn in the bed.)
d. If patient is assisting in turning, turn the
patient on side facing raised side rail, toward
the nurse. (Prevents patient from falling out of
bed.) If patient is not assisting, then use the lift
sheet to turn the patient.
e. Flex one of patient’s legs over the other. Place
pad or pillow between legs. (Reduces pressure
on lower leg and prevents skin breakdown by
avoiding skin on skin.)
f. Align patient’s shoulders; place pillow under
head. (Ensures proper body alignment.)
g. Support patient’s back with pillows as
necessary. A “tuck back” pillow is made by
folding pillow lengthwise. Tuck smooth area
slightly under patient’s back. (Helps keep patient
in position.)
Step 11e
f. Another way to accomplish this is by rolling
the patient onto his or her side before sitting
the patient up. (Decreases the amount the nurse
needs to lift because the patient’s body weight
actually helps the patient to sit upright.) The
nurse then stoops and, when standing, brings
the patient along with the nurse. (This causes
less back strain for the nurse and the patient does
not feel pulled on.)
g. Help patient place slippers on; cover legs.
(Prevents patient from becoming chilled.) For
safety, have patient place slippers on while in
bed.
h. Assess patient’s pulse and respirations.
(Determines patient’s response to procedure.)
176
UNIT II Fundamentals of Clinical Practice
Skill 8-3 Moving the Patient—cont’d
12. Log-rolling the patient (back, neck, or head
conditions sometimes necessitate log-rolling after
injury or surgery):
a. Enlist the help of at least one additional
person. (Ensures patient safety.)
b. Lower the head of the bed as much as the
patient can tolerate. (Maintains alignment of the
spinal column.)
c. Place a pillow between the patient’s legs. Use
of a pull sheet placed between shoulders and
knees facilitates turning (see Step 9g[1]).
(Maintains position of the lower extremities.)
d. Extend the patient’s arm over the patient’s
head unless shoulder movement is restricted.
(Prevents rolling over it during the turn.) If
shoulder movement is restricted, keep the arm
in extension next to the body.
e. With both nurses on the same side of the bed,
one of the nurses places one hand on the
patient’s shoulder and the other on the hip,
while the other nurse places one hand to
support the patient’s back and the other
behind the knee. If a lift sheet is used, space
hands in such a way to provide even support
for the length of the rolled sheet and to
distribute weight evenly.
f. On a count of 3, turn the patient with a
continuous, smooth, and coordinated effort.
(Maintains body alignment, preventing stress on
any part of the body.)
g. Support the patient with pillows as previously
discussed (see Step 10g). (Promotes patient
comfort.)
13. Transferring the patient from bed to straight chair
or wheelchair:
a. Lower bed to lowest position. (Provides patient
safety when getting up.)
b. Raise head of bed. (Patient can more easily swing
around to sitting position.)
c. Support patient’s shoulders and help swing
legs around and off bed; perform all in one
motion. (Prevents strain on patient, especially if
patient has incision.)
Step 12e
Step 13c
d. Help patient don robe and slippers (or do
this before beginning procedure). (Prevents
chilling.)
e. Have chair positioned beside bed with seat
facing foot of bed. (Provides easy access to
chair.)
Body Mechanics and Patient Mobility CHAPTER 8
177
Skill 8-3 Moving the Patient—cont’d
(1) Place wheelchair at right angle to bed and
lock wheels after bed is lowered. (Provides
safety.)
(2) Place straight chair against wall or have
another nurse hold the chair. (Provides
safety.)
f. Stand in front of patient and place hands at
patient’s waist level or below; allow patient
to use his or her arms and shoulder muscles
to push down on the mattress to facilitate
the move. (Prepares the patient for movement
to chair.)
i. Apply blanket to legs. (Provides extra warmth.)
j. If transfer belt is used, apply after patient is
sitting on side of bed and follow these
guidelines:
(1) Stand in front of the patient. (Permits
excellent view of patient.)
(2) Have the patient hold on to the mattress,
or ask the patient to place his or her fists
on the bed by the thighs. (Any assistance
from the patient minimizes strain on you.)
(3) Be sure the patient’s feet are flat on the
floor. (Provides balance and stability for
patient.)
(4) Have the patient lean forward.
(5) Instruct the patient to place his or her
hands on the nurse’s shoulders, not
around the nurse’s neck or at the side as
shown. (Arms around the neck could result
in neck injury to nurse.)
(6) Grasp the transfer belt at each side.
(Offers stability of patient for the nurse.)
(7) Brace knees against the patient’s knees.
Block the patient’s feet with the nurse’s
feet. (Provides safety and prevents patient’s
foot from slipping.)
Step 13f
g. Assist patient to stand and swing around with
back toward seat of chair. Keep the strong side
toward the chair. (Provides safety.)
h. Help patient to sit down as the nurse bends
his or her knees to assist process. (Prevents
patient from slipping and falling. If patient begins
to fall, prevent patient injury by holding patient
and allowing patient to sit down gently on floor;
see Box 8-2, step 3.)
Step 13j(7)
Prevent the patient from sliding or falling by bracing the patient’s
knees and feet with your own knees and feet.
Step 13h
Skill 8-3 Moving the Patient—cont’d
(8) Ask the patient to push down on the
mattress and to stand on the count of 3.
Pull the patient into a standing position
as you straighten your knees. (Provides for
less strain on your back.)
Step 13j(8)
The patient is pulled up to a standing position and supported by
holding the transfer belt and blocking the patient’s knees and feet.
(9) Pivot the patient so he or she is able to
grasp the far arm of the chair. Back of the
legs will be touching the chair. (Enables
patient to assist in the transfer.)
(10) Continue to turn the patient until the
other arm rest is grasped.
(11) Gradually lower the patient into the chair
as you bend your hips and knees. The
patient assists if able by leaning forward
and bending his or her elbows and knees.
(Encourages patient to assist in transfer and
increases muscle strength and a sense of
control.)
(12) Ensure buttocks are to the back of the
chair. (Ensures patient safety.)
(13) Cover patient’s lap and legs. (Promotes
patient’s comfort and privacy.)
14. Transferring from bed to stretcher or gurney back
to bed:
a. Position bed flat and raise to the same height
as stretcher or gurney. Lower side rails.
(Facilitates procedure.)
b. Cover patient with top sheet or blanket and
remove linens without exposing patient.
(Provides privacy.)
c. Assess for IV line, Foley catheter, tubes,
or surgical drains, and position them to
avoid tension during the transfer. (Prevents
accidental tension and possible removal
of tubes.)
Step
Step
Step
Step
d. Position the gurney as close to the bed as
possible, and lock the wheels of the bed and
gurney (with side rails lowered). (Ensures
patient’s safety.)
e. When patient is able to assist, stand near side
of gurney and instruct patient to move feet,
then buttocks, and finally upper body to the
gurney, bringing blanket along. Be certain
patient’s body is centered on the gurney.
(Promotes safety and security.)
f. When patient is unable to assist, place
a folded sheet or bath blanket under the
patient so that it supports patient’s head and
extends to mid-thighs. Roll the sheet or bath
blanket close to the patient’s body. Assist
patient to cross arms over chest. Two nurses
reach over the bed to patient, and two more
nurses stand as close to the gurney as possible.
A fifth nurse stands at the foot to transfer the
feet. Using a coordinating count of 3, all five
nurses lift the patient to the edge of the bed.
With another effort, lift the patient from edge
of bed to gurney. Roller devices are available
in some facilities to facilitate this transfer.
Step 14f
15. Perform hand hygiene. (Reduces spread of
microorganisms.)
16. Assess patient for appropriate body alignment
after move. When repositioning, always assess
previously dependent skin surfaces (pressure
areas). Position pillows for comfort. Do not
overtire patient during ambulation. As in all
transfers, be certain call device is in easy reach.
(Evaluates, determines, and promotes patient safety
and comfort.)
17. Document procedure. (Notes procedure and
patient’s response.)
• Patient’s response
• Expected and unexpected outcomes
• Patient teaching (see Patient Teaching and
Home Care Considerations boxes)
9c(4), 12e, 13j(7), 13j(8) figures from Sorrentino SA: Assisting with patient care, ed 2, St. Louis, 2004, Mosby.
11e figure from Perry AG, & Potter PA: Clinical nursing skills and techniques, ed 7, St. Louis, 2010, Mosby.
13c, step 13f, step 13h figures from Potter PA, & Perry AG: Basic nursing: Essentials for practice, ed 6, St. Louis, 2006, Mosby.
14f figure from Elkin MK, Perry AG, & Potter PA: Nursing interventions and clinical skills, ed 4, St. Louis, 2008, Mosby.
Body Mechanics and Patient Mobility CHAPTER 8
patients do not become too dependent on assistance
with mobility. Frequent assessment of the patient’s
ability to assist with mobility is necessary to prevent
overdependence. The LPN/LVN should also assess
the patient for pain and administer pain medications
before activities that cause further pain (Box 8-3; see
the Coordinated Care box).
USE OF THE LIFT FOR MOVING PATIENTS
Mechanical devices, such as the patient lift with a sling
(Figure 8-7), are useful for moving patients safely and
protecting the nurse’s back and for full-weight lifting
of patients who cannot assist. Follow agency policy for
use of the lift (Skill 8-4).
NURSING PROCESS FOR
PATIENT MOBILITY
The role of the LPN/LVN in the nursing process as
stated is that the LPN/LVN:
• Participates in planning care for patients based on
patient needs.
• Reviews the patient’s plan of care and recommends
revisions as needed.
• Reviews and follows defined prioritization for
patient care.
• Uses clinical pathways, care maps, or care plans to
guide and review patient care.
Assessment
Assessment focuses on ROM, muscle strength, activity
tolerance, gait, and posture. Observation during ADLs
enables the nurse to estimate the patient’s fatigability,
muscle strength, and ROM. Further assessment helps
determine the type of assistance the patient needs to
change position or transfer from bed to chair or wheelchair. These assessments give the LPN/LVN an understanding of the patient’s overall level of mobility and
coordination (see the Cultural Considerations box).
Coordinated Care
Box 8-3 Long-Term Care Considerations for Mobility
Delegation
• Patients who have maintained bed rest for a long time
sometimes revert back to a favorite position.
Frequently assess these patients, and turn them more
often as needed.
• Use a lift (draw) sheet as often as possible to prevent
shearing force on fragile skin.
• Allow the patient to assist with moving and positioning
whenever possible to promote independence.
• Perform safety and maintenance checks of ambulation
devices on a routine basis.
• Perform periodic assessments to ensure that the
patient is using ambulation device properly.
• Consult the physical therapist for additional assistance
or exercises and to ascertain the patient’s response to
the exercise program.
• Group activities (e.g., simple games, walking, tossing
a ball in a large circle) are useful in maintaining ROM.
Mobility
The following information is needed when delegating the skill
of position changes to UAP:
• Have the patient wear shoes with a nonslip surface during
transfer or ambulation.
• Make slow, gradual position changes.
• Help the patient sit in a chair or return to bed if the patient
has symptoms of orthostatic hypotension.
• When assisting with ambulation:
• Do not try to hold patients if they become dizzy or faint.
Ease them into a sitting position in a chair or onto the
floor.
• Use assistive devices such as walkers, crutches, gait
belt, or cane when appropriate.
• Be sure the area is free of clutter, wet areas, and rugs
that may slide.
A
179
B
FIGURE 8-7 A, Motorized lift. B, Use of a mechanical lift to lower patient into chair. (From Potter PA, Perry AG,
Stocket PA, et al.: Basic nursing, ed 7, St. Louis, 2011, Mosby.)
180
UNIT II Fundamentals of Clinical Practice
Skill 8-4
Using Lifts for Moving Patients
NURSING ACTION (RATIONALE)
1. Refer to medical record or care plan for special
interventions. (Provides basis for care.) Read
manual for direction.
2. Assemble equipment:
• Mechanical lift frame (see Figure 8-7)
• Seat sling attachment (may be one piece or
two) or a standing frame
• Two cotton bath blankets
3. Introduce self. (Decreases patient’s anxiety.)
4. Identify patient. (Ensures procedure is performed
with correct patient.)
5. Explain procedure. (Enlists cooperation and
assistance from patient and decreases patient’s
anxiety.)
6. Perform hand hygiene. (Reduces spread of
microorganisms.)
7. Prepare patient for interventions.
a. Close door or pull curtains. (Provides privacy.)
b. Adjust bed level to working height (even with
level of arm of chair [of lift] if chair is not
removable or level with seat if chair is
removable.) (Promotes safety.)
c. Medicate patient as needed. (Promotes patient
comfort.)
d. Place cotton bath blanket over chair for
patient’s comfort.
e. Cover patient with remaining bath blanket.
8. Secure adequate number of personnel. (Provides
necessary assistance and patient safety.)
9. Place chair near bed. (Prepares seat for patient.)
Cultural Considerations
Promotion of Patient Mobility
• Assess and listen carefully to patient’s expressions of
health and illness beliefs and practices.
• Be aware of the patient’s personal space; seek
permission before intruding in the patient’s territory.
• The nursing process enables the nurse to provide
individualized care; adapt care to be culturally sensitive.
• When speaking with a patient (or family member) who
does not understand English, many people try to
compensate for the lack of understanding by speaking
more loudly. Speaking slowly, distinctly, and in a normal
volume is more effective (see Chapter 6).
10. Appropriately place canvas seat under patient;
support head and neck. (Helps in lifting safely.)
11. Slide horseshoe-shaped bar under bed on one
side. (Places lift close to bed.)
12. Lower horizontal bar to level of sling. (Places lift
close to patient.)
13. Fasten hooks on chain to openings in sling.
(Attaches lift to sling seat.)
14. Raise head of bed. (Places patient in sitting position.)
15. Fold patient’s arms over chest. (Prevents patient
injury.)
16. Pump lift handle until patient is raised off bed.
(Ensures patient safety during lifting.)
17. With steering handle, pull lift off bed and down
to chair. (Places patient safely in chair provided.)
18. Release valve slowly to lift and lower patient
toward chair. (Appropriately places patient in chair.)
19. Close off valve and release straps. (Prevents
patient injury from boom.)
20. Remove straps and lift. (Provides safety and
comfort.)
21. Perform hand hygiene. (Reduces spread of
microorganisms.)
22. Document procedure. (Note procedure and patient’s
response.)
• Evaluate body alignment to help prevent skin
impairment.
• Evaluate patient’s response to movement to
help determine patient’s mobility potential.
23. Perform patient teaching (see Patient Teaching
and Home Care Considerations boxes).
It is acceptable to delegate the skills of safe and
effective transfer from bed to chair to UAP who have
successfully demonstrated good body mechanics and
safe transfer techniques for patients involved.
Teaching patients how to use assistive devices
requires critical thinking and knowledge application
unique to a nurse. However, UAP are able to assist
ambulatory patients with assistive devices.
• Have patient wear shoes with a nonskid surface
during ambulation.
• Be sure the area is free of clutter, wet areas, and rugs
that may slide or buckle.
• Ensure UAP know how to use an intravenous (IV)
pole to assist in ambulation for patients with continuous IV therapy.
• Be sure the patient uses the correct gait and weight
bearing during ambulation.
Body Mechanics and Patient Mobility CHAPTER 8
• Ease patients to a sitting position in a chair or on
the floor if they become dizzy or faint.
• Alert the LPN/LVN if a patient becomes dizzy or
lightheaded or suffers a fall.
The skill of performing ROM exercises can be delegated to UAP. Patients with spinal cord or orthopedic
trauma or surgery usually require exercise by nurses
or physical therapists. When delegating this skill, the
nurse should instruct UAP to perform exercises slowly
and provide adequate support to the joint being exercised. In addition, the nurse should remind UAP not
to exercise joints beyond the point of resistance or to
the point of fatigue or pain. In addition, if muscle
spasms occur, exercise should stop until the spasms
have subsided.
The nurse may delegate the skill of safe and effective transfer with a mechanical lift to UAP who have
demonstrated ability to use good body mechanics and
safe transfer techniques and equipment (mechanical
lift).
Nursing Diagnosis
Assessment enables the nurse to cluster relevant data
and develop actual or potential (risk) nursing diagnoses related to the patient’s needs. The nursing
181
diagnoses are stated along with the probable causes
“related to (r/t).” Identification of the cause of the
problem further individualizes the care plan and leads
to selection of appropriate care.
Example: Impaired physical mobility r/t activity intolerance secondary to left shoulder pain, 5/10.
Expected Outcomes and Planning
The nurse should set goals and expected outcomes
with the patient to direct interventions. Care planning
is individualized to the patient, with the patient’s most
immediate needs taken into consideration. These goals
are based on the nursing diagnosis formulated.
Goal: Patient will demonstrate increased activity
tolerance.
Expected outcomes: Patient dangles legs or sits without
vertigo, weakness, or orthostatic hypotension for 5
minutes with assistance.
Implementation
Nursing interventions should be individualized according to the level of risk to the patient. The nurse, the
patient, and other members of the health care team
work together to determine the most effective interventions (Nursing Care Plan 8-1). While implementing
Nursing Care Plan 8-1 The Patient with Activity Intolerance
Mr. D., a 56-year-old patient hospitalized with multiple orthopedic traumas, reports pain in his left shoulder during movement. He also reports difficulty extending his shoulder joint in carrying out activities of daily living. The nurse observes
that he limits motion in his left arm. Range of motion (ROM) is reduced 30 degrees during abduction of arm.
NURSING DIAGNOSIS
Impaired bed mobility, related to (r/t) left shoulder pain as evidenced by (AEB) limited mobility of left arm, c/o (complaints
of) pain and favoring left arm
Patient Goals and
Expected Outcomes
Patient will gain optimal
ROM of left shoulder
within 4 mo
Patient will perform
self-care activities using
left arm within 2 days
Patient will report
decreased pain.
Patient will increase ROM
in upper extremity
joints by 20 degrees
Patient will follow a
regular exercise
program by discharge
Nursing Interventions
Evaluation
Offer analgesic 30 min before ROM exercises (peak action of
analgesic will occur as patient begins exercises).
Schedule active ROM exercises between meals and hygiene
activities (promotes frequent exercise to affected joints
and reduces risk of contracture development).
Teach patient specific ROM exercises for left shoulder and
arm. (Teaching provides the patient with opportunity
and knowledge to maintain and increase ROM.) (See
Patient Teaching and Home Care Considerations boxes
on mobility.)
Ask patient to report changes
in perception of left
shoulder pain, using a
scale of 1 to 10.
Observe patient while doing
ROM exercises in upper
extremities and while
doing self-care to
determine increase of 20
degrees of upper
extremities by time of
discharge.
Critical Thinking Questions
1. The nurse is in the process of transferring Mr. D. from his bed to a chair with use of a mechanical lift. The nurse has
prepared the chair and placed it near the bed. The nurse turns Mr. D. to his side, places the sling under Mr. Davis to
ensure adequate support of his head, returns Mr. D. to his back, and slowly begins to lift him from his bed. What has
the nurse forgotten to do, and why is it important?
2. The patient has a trapeze bar across the bed, trochanter rolls, and a footboard. Explain the rationale for use of each of
these devices to maintain proper body alignment.

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